|
|
 |
 |
 |
|
|
|||
|
||||
|
||||
Interesting CaseFrom: rkaplan@triad.rr.comThu May 21 20:12:24 2009
You (or your wife) are now 30 weeks pregnant. Ultrasound at 20 weeks showed normal fetal anatomy but growth was 2 weeks behind date proposed by ultrasound at 7 weeks. Work up for early FGR (TORCH studies) were all negative. At 29 weeks there is another week lag from the scan at 20 weeks and umbilical cord study shows no end diastolic flow. The fetus is symmetric (head circumference = abdominal circumference), amniotic fluid index is normal and fetal Biophysical Profile (BPP) is 10/10. You (or your wife) are admitted, given steroids for fetal lung maturation, and placed on continuous fetal monitoring. Repeat ultrasound in the hospital by the perinatologist confirms no end diastolic flow, symmetric FGR, and normal BPP. While on continuous monitoring, your fetus has U shaped decels which dropped from 120 to 70 bpm and last from 1-2 minutes (would meet the criteria of severe variable decels if you were in labor). These decels occur sometimes 30 minutes apart and sometimes 2 or more hours apart. At all other times the FHT shows excellent variability and spontaneous accels. You feel good fetal movement and do not feel any contractions nor are any contractions seen on the tracing. You have 2 more ultrasounds in the hospital which confirm the absence of end diastolic flow but normal BPP. Your perinatologist knows that you are an experienced Ob care provider. She knows that you understand the risks of neonatal complications that can occur in the 30 week newborn. She also feels very uncomfortable with these random decels in a growth restricted 30 week fetus with absent end diastolic flow, even though the fetus is growing symmetrically and the BPP is 10/10. She asks you: Do you want a Cesarean (fetus is in the breech presentation) now? Do you want to continue the pregnancy? Would a good, hard contraction stress test (CST) help you make your decision? Richard Kaplan Greensboro PS. For extra credit: What is the risk of stillbirth within 48 hours of a BPP 10/10? Within 48 hours of a negative CST? Does the presence of growth restriction or an abnormal cord dopler make these tests less sensitive? What is the risk of neonatal death at 30 weeks after steroids in a level 3 nursery? What is the etiology or pathophysiolgy of random decels seen on continuous fetal monitoring in the absence of labor? PPS. I posed this in the first person because I do not want to hear about what course of action is least likely to get you sued.
|
|
Return to
|
Mail a New Message to the Forum: ob-gyn-l@obgyn.net Forum Administrator: geffrey.klein@obgyn.net Report Technical Problems: webmaster@obgyn.net Last Updated: Mon Nov 2 05:14:36 2009 |
The American Medical Association is no longer designating CME hours for AMA Category II CME credit. However, physicians themselves may self designate learning activities as Category II CME credit hours if they feel it is of sufficient educational merit and meets the formal definitions of continuing medical education. OBGYN.net believes these interaction in this forum meets these criteria. For further information see the AMA web site.